1. Pulmonary Arteriography Mediastinum: heart & great vessels Superior & inferior vena cava: Rt atrium Ascending, descending, & arch of aorta: (Lt ventricle) Pulmonary trunk: (Rt ventricle) Pulmonary veins: Lt atrium Rt & Lt pulmonary arteries (lobar and segmental branches)

2. Atlas of Human Anatomy Second edition (201) Mediastinum: heart & great vessels Superior vena cava (to Rt atrium) Ascending, descending, & arch of aorta (from Lt ventricle) Pulmonary trunk (from Rt ventricle) Rt and Lt hemidiaphragm (domes of)

3. Radiographic Anatomy of PA Chest Right pulmonary artery Left pulmonary artery Pulmonary trunk

4. Pulmonary Arteriography Indications * Chest pain * Dyspnea * SOB * Pulmonary emboli * Pumonary stenosis * Patent ductus arteriosis Contraindications * Cardiac dysrhythmias * PVCs * Pulmonary edema (rales) * Pulmonary hypertension (mean > 60mmHg vs normal of 15)

5. Approaches for Pulmonary Arteriography * Femoral vein unless contraindicated by thrombi * Axillary vein * Antecubital vein: peripheral using DSA * Antecubital vein cutdown (Right arm in abduction, valsalva maneuver)

6. Equipment for Pulmonary Arteriography * 6-7 f Grollman pigtail catheter * Side and end, or just side holes with sheath* *.038 J, moveable core GW * 12 – 16 gauge needle for venous stick Shape of the Grollman catheter * A catheter without an end hole has less recoil during injection, but a guidewire cannot be used with it, so a long sheath is placed in position, and the catheter is introduced through it.

7. Pulmonary Trunk Pressure Pressure in the right or left pulmonary arteries, though slightly higher, is similar to that in the trunk vessel. TTP Q R S SystoleDiastole mm Hg 10 5 20 15 Pulmonary hypertension 60 mmHg Pulmonary artery: mean 9-17 Systolic 15-30, Diastolic 4-14

8. NG tubeET tube Swan-Ganz catheter: For taking pressures in the pulmonary artery, and monitoring oxygen saturation. Note its appearance in the LPO position

9. Filming Pulmonary Arteriograms Right Pulmonary artery Left Pulmonary artery AP projection of pulmonary trunk injection

10. Filming Pulmonary Arteriograms AP projection of selected right pulmonary artery

11. 10-15 degrees LPO position for Rt Pulmonary A Filming Pulmonary Arteriograms

12. RPO position for Lt Pulmonary A 30-45 degrees

13. Filming Pulmonary Arteriograms A 60 degree LPO of the left pulmonary artery Scout film

14. Pulmonary Stenosis Pulmonary valve is narrow, blocking adequate blood flow to the lungs.

15. Pulmonary Stenosis Signs and Symptoms: SOB fatigue cyanosis chest pain failure to thrive in infants inability to tolerate exercise CHF and sudden death

16. Pulmonary Stenosis: Congenital Etiology (Idiopathic) * Occurs during fetal development * Common with other heart defects Non congenital causes * Rheumatic Fever * Endocarditis

17. Treatment options Pulmonary valvuloplasty Open heart surgery

18. Pulmonary Emboli (PE) This Greenfield caval filter is in the inferior vena cava. It is introduced through the right internal jugular or femoral vein If the filter were not present, clots would travel to the right heart, pulmonary artery, and the arterioles of the lungs. Such filters are commonly impregnated with a thrombolytic agent, and once implanted, are not removed. Other types of caval filters are the bird’s Nest, Vena Tech LGM and LP, Simon Nitinol and TrapeEase.